Athlete Registration Form for US Programs – updated July 2017 (SOI) ATHLETE INFORMATION FORM Please submit to [email protected]ATHLETE INFORMATION First Name: Middle Name: Last Name: Preferred Name: Date Birth (mm/dd/yyyy): ☐ Female ☐ Male Race/Ethnicity (Optional): ☐ American Indian/Alaskan Native ☐ Black or African American ☐ White ☐ Asian ☐ Two or More Races ☐ Native Hawaiian or Other Pacific Islander ☐ Hispanic or Latino (specific origin group:_________________________) Language(s) Spoken in Athlete’s Home (Optional): Check all that apply ☐ English ☐ Spanish ☐ Other (please list): Street Address: City: State: Postal Code: Phone: E-mail: Sports/Activities: Athlete Employer, if any (Optional): Does the athlete have the capacity to consent to medical treatment on his or her own behalf? ☐Yes ☐ No PARENT / GUARDIAN INFORMATION (required if minor or otherwise has a legal guardian) Name: Relationship: ☐ Same Contact Info as Athlete Street Address: City: State: Postal Code: Phone: E-mail: EMERGENCY CONTACT INFORMATION ☐ Same as Parent/Guardian Name: Phone: Relationship: PHYSICIAN / INSURANCE INFORMATION Physician Name: Physician Phone: Insurance Company: Insurance Policy Number: Insurance Group Number: Special Olympics Iowa Delegation/Team: ___________________________________ Are you a new athlete to Special Olympics or Re-Registering? ☐ New Athlete ☐ Re-Registering Has the athlete’s Health History changed in the last three years? If Yes please submit an updated Health History along with the Exam. ☐ Yes ☐ No
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ATHLETE INFORMATION FORM - Special Olympics · PDF file☐☐ English ☐ Spanish Other (please list): Street Address: City ... Special Olympics to seek medical care on my behalf,
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Athlete Registration Form for US Programs – updated July 2017 (SOI)
Date of Birth: _________ / _________ / _________ Gender: Female Male
I agree to the following:
1. Ability to Participate. I am physically able to take part in Special Olympics activities.
2. Likeness Release. I give permission to Special Olympics to use my photo, video, name, voice, and words to promote Special Olympics and raise funds for Special Olympics. For this form, “Special Olympics” means all Special Olympics organizations.
3. Risk of Concussion and Other Injury. I know there is a risk of injury. I understand the risk of continuing to play sports with a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again.
4. Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency, I authorize Special Olympics to seek medical care on my behalf, unless I mark one of these boxes:
I have a religious or other objection to receiving medical treatment. I do not consent to blood transfusions.
(If either box is marked, an EMERGENCY MEDICAL CARE REFUSAL FORM must be completed.)
5. Overnight Stay. For some events, I may stay in a hotel or someone’s home. If I have questions, I will ask.
6. Health Programs. If I take part in a health program, I consent to health activities, screenings, and treatment. This should not replace regular health care. I can say no to treatment or anything else at any time.
7. Personal Information. I understand that Special Olympics is collecting my personal information.
I consent to Special Olympics using my personal information in order to: make sure I am eligible and can participate safely; run trainings and events; share competition results (including on the Web and in news media); provide health treatment if I participate in a health program; analyze data for the purposes of improving programming and identifying and responding to the needs of Special Olympics participants; perform computer operations, quality assurance, testing, and other related operations and activities; and provide event-related services.
I consent to Special Olympics using my email address and creating a profile of me for communications and marketing purposes.
I understand that Special Olympics may disclose my personal information to medical professionals in the event of an emergency and to third party researchers to analyze data for the purposes of improving Special Olympics programming and identifying and responding to the needs of Special Olympics participants.
I understand that Special Olympics may disclose my personal information to government authorities for the purpose of assisting me with any visas required for international travel to Special Olympics events and for any other purpose necessary to protect public safety, respond to government requests, and report information as required by law.
I understand Special Olympics is a global organization with headquarters in the United States of America. I consent to Special Olympics storing and processing my personal information in countries, including the United States of America, that have laws requiring a different level of privacy and data protection.
I have the right to ask to see my personal information or to be informed about the personal information that is processed about me. I have the right to ask to make changes to or delete my information.
ATHLETE SIGNATURE (required for adult athlete with capacity to sign legal documents) I have read and understand this form. If I have questions, I will ask. By signing, I agree to this form.
PARENT/GUARDIAN SIGNATURE (required for athlete who is a minor or lacks capacity to sign legal documents)
I am a parent or guardian of the athlete. I have read and understand this form and have explained the contents to the athlete as appropriate. By signing, I agree to this form on my own behalf and on behalf of the athlete.
Athlete shows NO EVIDENCE of neurological symptoms or physical findings associated with spinal cord compression or atlanto-axial instability.
OR
Athlete has neurological symptoms or physical findings that could be associated with spinal cord compression or atlanto-axial instability and must receive an additional neurological evaluation to rule out additional risk of spinal cord injury prior to clearance for sports participation.
ATHLETE CLEARANCE TO PARTICIPATE (TO BE COMPLETED BY EXAMINER ONLY) Licensed Medical Examiners: It is recommended that the examiner review items on the medical history with the athlete or their guardian, prior to performing the physical exam. If an athlete needs further medical evaluation please make a referral below and second physician for referral should complete page 4.
This athlete is ABLE to participate in Special Olympics sports without restrictions.
This athlete is ABLE to participate in Special Olympics sports WITH restrictions. Describe ___________________________________________
This athlete MAY NOT participate in Special Olympics sports at this time & MUST be further evaluated by a physician for the following concerns:
Concerning Cardiac Exam Acute Infection O2 Saturation Less than 90% on Room Air
Concerning Neurological Exam Stage II Hypertension or Greater Hepatomegaly or Splenomegaly
Other, please describe:
Additional Licensed Examiner’s Notes and Recommended (but not required) Follow-up:
Follow up with a cardiologist Follow up with a neurologist Follow up with a primary care physician
Follow up with a vision specialist Follow up with a hearing specialist Follow up with a dentist or dental hygienist
Follow up with a podiatrist Follow up with a physical therapist Follow up with a nutritionist
Other/Exam Notes:
Name:
E-mail:
Signature of Licensed Medical Examiner Exam Date Phone: License #:
Athlete’s First and Last Name:_______________________________________________
Medical Form for US Programs – updated July 2017 Special Olympics Medical Form | 4 of 4
Athlete Medical Form – MEDICAL REFERRAL FORM (To be completed by a Licensed Medical Professional only if referral is needed)
This page only needs to be completed and signed if the physician on page three does not clear
the athlete and indicates further evaluation is required.
Athlete should bring the previously completed pages to the appointment with the specialist.